What is the treatment for Helicobacter pylori (H. pylori) infection?

From the Guidelines

The most effective treatment for H. pylori infection is standard triple therapy with a proton pump inhibitor (PPI), amoxicillin, and clarithromycin, which should be used as first-line therapy if low clarithromycin resistance is present 1. This regimen has been shown to be effective in eradicating H. pylori infection and reducing the risk of recurrent bleeding in patients with bleeding peptic ulcers. The recommended doses are:

• PPI standard dose twice a day
• Clarithromycin 500 mg twice a day
• Amoxicillin 1000 mg twice a day Alternatively, a 10-day levofloxacin-amoxicillin triple therapy can be used as second-line therapy if first-line therapy fails 1. Some key points to consider when treating H. pylori infection include:
• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community 1
• Antibiotic resistance is increasing globally, so adherence to the complete regimen is crucial for successful eradication 1
• Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and after stopping PPI for 2 weeks
• Patients should be advised to avoid alcohol during treatment due to potential interactions with metronidazole 1

From the FDA Drug Label

Adult Patients only Helicobacter pylori Infection and Duodenal Ulcer Disease: Triple therapy for Helicobacter pylori (H. pylori) with clarithromycin and lansoprazole : Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. Dual therapy for H. pylori with lansoprazole : Amoxicillin, in combination with lansoprazole delayed-release capsules as dual therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) who are either allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected.

H. pylori treatment options with amoxicillin include:

• Triple therapy: amoxicillin, clarithromycin, and lansoprazole
• Dual therapy: amoxicillin and lansoprazole, for patients who are allergic or intolerant to clarithromycin, or in cases of known or suspected clarithromycin resistance 2

From the Research

H pylori Treatment Options

• The Toronto Consensus recommends that all H pylori eradication regimens be given for 14 days due to increasing failure of therapy 3.
• First-line strategies include concomitant nonbismuth quadruple therapy (PPI + amoxicillin + metronidazole + clarithromycin) and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline) 3.
• PPI triple therapy is restricted to areas with known low clarithromycin resistance or high eradication success with these regimens 3.

Comparison of Treatment Regimens

• A meta-analysis found that proton-pump inhibitor and amoxicillin-based triple therapy containing clarithromycin (PAC) and metronidazole (PAM) had comparable eradication rates (71.0% vs 75.2%) 4.
• PAM was found to be highly effective in clarithromycin-resistant cases, while PAC showed significant efficacy in metronidazole-resistant cases 4.
• A review of pharmacotherapy options found that bismuth quadruple therapy is recommended as the best initial empiric treatment due to the declining efficacy of legacy triple therapies 5.

Quadruple Therapy Regimens

• A study found that a new quadruple therapy regimen (amoxicillin + metronidazole + omeprazole + clarithromycin) was effective and safe for H pylori eradication, with an eradication rate of 96% 6.
• Another study found that nonbismuth quadruple therapies (sequential, concomitant, and sequential-concomitant hybrid) are viable first-line regimen options in regions with high clarithromycin resistance 7.

Treatment Duration and Resistance

• The Toronto Consensus recommends a 14-day treatment duration for all H pylori eradication regimens due to increasing antibiotic resistance 3.
• A review found that susceptibility-guided treatment appears to be the ideal approach, but the feasibility and cost-effectiveness of universal pre-treatment susceptibility testing warrants further evaluation 5.